TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID- _'^ki'}__. Date- _^yj^jj_v 

Addres.s. U U 0 H 

Reniediation Conlraclor. Coastal Environmenta) Group Year: iOJOARRA 

SOILREMEDIATJON 

PROPERTV FILE FOLDER DOCUMENTS 

Video of property (DVD) 

y Executive Summary 

y EPA-provided property sketch 

Signed Access Agreement for subject properly 

y Signed Access Agreement(s) for adjacenl property 

Restoration Agreement 

Y Settlement documents (i.e., for damage or to replace plants, elc.) 

Confirmation data 

p 7 Photographs 

y As-buill sketch 

y Satisfactory restoration signed by Property Owner 

y Property close-out check list signed by EPA 

Description of areas not meeting ROD cleanup criteria 

Utility clearances 

^ Property information from Douglas County Assessor's Office 

Superfund 
vv 

Property Access Checklist 

Property ID: Hi^ B - H D WORK STARTED ON: / / 

PropertyAddress D WORK COMPELTED ON:. / / : \^Z ^ / O ^S-/ " 

Owner: Renter: • ^WT ^ 

Address: Phone: 

Fax: 

Ceil/Pager: 

Phone: Additional Information: ^W ^i < 

Fax: 

Cell/Pager: 

D Notification Letter Sent: / / By: 

^ Access Agreement Signed: pl/i . If O By: U:cV 

[^ Restoration Agreement Signed: 4^^/ ^ 

By: w-,cX 

D Topsoil Sampling (if applicable) / / By: 

O Disposal Sampling (if applicable) / / By: 

Q Garden Sampling (if applicable) / / By: 

13 Utility Clearance CaUed: \ \ / "5 / \ o 

By: vv./<v/io VJ^^IM.. ^ 

1 ^ Video/Photos (Before) On: 10 /Z\, 1 / o 

By: K...VL 

D Video/Photos (During) On: / / By: 

D Video/Photos (After) On: / / By: 

n Video/Photos (30-Day) On: / / By: 

O Property Completion Agreement Siened: / / By: 

G Final Report Issued: / / By: 

Air Monitoring (as applicable) 

• Conununity • Crew On: / / By: 1 

Results: 

• Conununity • Crew On: / / By: 

Results: 

• Community • Crew On: / / By: 1 

Results: 

Omaha Lead Site 
Douglas County Account ^|^|ation Page 1 of2 

Douglas County, Nebraska Property Record - R0414140000 

Print Reoort 

View interactive GiS Mao Information is valid as of 2010-8-30 Treasurer's Tax Report 

New Feature «t'^ ^ Subdivision Sales Search 

Owner 

CHAVF7JUAN 

4932 S 19 ST 

OMAHA NE 68107-0000 

Property Informatio n 

Key Numtter: 1414 0000 04 

Account Type: Residential 

Parcel Numlier: 0414140000 

Parcel Address: 1822 OST 

OMAHA NE 68107-0000 

Legal Description: SOUTH OMAHA CITY LOTS LOT 11 BLOCK 108 W 40 FT LT 10 & W 40 S 25 FT 

40X75 

Value Informatio n 

2010 

2009 

2008 

2007 

2006 

2005 

Land 

$300.00 

$300.00 

$300.00 

$300.00 

$300.00 

$300.00 

improvement 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Totai 

$300.00 

$300.00 

$300.00 

$300.00 

$300.00 

$300.00 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.06 3000.0 0.0 75.0 40.0 Yes 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R04... 9/15/2010 
Page 1 of2 

"> 

[ Create Another Ticket ] Back to Irth Intemet ] Send Email 

• YOUR TICKET NUMBER IS 2635799. 

Original Call Date: 11/05/10 Time: 12:15 pm Op: ELIZABETH18790 

Work to Begin Date: ll/09/lO Time: 12:45 pm 

State: NE County: DOUGLAS Place: OMAHA 

Address: 1822 Street: O ST 

Twp: 14N Rng: 13E Sect-Qtr: 03-SW 

Twp: Rng: Sect-Qtr: 

Legal Given: C 


Type of Work: LEAD REMEDIATION 


Location of Work: LOCATE ENTIRE PROPERTY, ALL EASEMENTS AND TO THE PEDESTAL 


Remarks: FAX ALL CLEARS TO: (877)662-4211 


: UNSURE IF CORNER LOT. 


Company : COASTAL ENVIRONMENTAL SERVICE 


Contact Name: ELIZABETH Phone: (877)662-4210 


Work Being Done For: COASTAL 


Depth of Excavation: 4 FT Comer Lot: N Front: Y Rear: 


Involves Tiinneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MUD02 OMAHACOF 0PPDGPR6 QLNNEIF 


Service Area Contact Phone Number UtiUty Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

LEVEL3 LEVEL3 COMMUNICATIONS, LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

MUD02 METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC,SEWER RICH/TRAFFIC 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 11/5/2010 
Page 2 of2 

OPPDGPR6 OMAHA PUBLIC POWER DISTRICT ELM LOCATING Alt: 4062071494 

Emerg: 8887289343 

QLNNEIF QWEST LOCAL NETWORK ELM LOCATING

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 11/5/2010 
^ As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

OLS# : 4858 7 

Dat e Excavated : 11/9/2010 

Dat e USEP A Signe d Off: 12/9/2010 

48587 

Are a Sodden : 870 s a ft 

Omah a Lea d Site Exterior Paint NcMth Arrow 

Owner Name: JUAN CHAVEZ D Good Site Sketc h Address: 1822 OST • Ppor ( 

Ptwne: H;«W-2:«55 * * Q/^lot paint 

Lead Sample 

pies Collected Sample Number l AB Concentration 

Collected Frm: 

RYASCPXA-48587 Fl ppm CK D Date: Cf\ ' o ^ O ^ 

RYBSCPXA-48S87 F2 __3ze_ ppm D Tjme; / . l y iJ.yi 

RYCSCPXA-48587 Bl _2jfe5_ ppm B^ D Samples Analyzed RYDSCPXA-48587 B2 ^3 7 ppm D 

nezocpxA-*oso7 

- B2 ppm D • XRF Unit Book; 13 2 

- 6 2 ppm D D Date: _ 7-OS -

RPgCCPXA 40007 -P2 - ppm D D 

3] 

Time: A i n 

staff: i-A Numlier of Samples = 

Omaha Lead Site 

46130 

Legend 

Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced

Sod 

 with Area replaced with 

Rock/Mulch Area left bare 

Contract #: EP-R7-07-05 Coastal Environmental Group Inc. 

48587 

C\ejKr L-V. vv/^ 

Omah Exterior Paint a Lead Site rl Owner Name: JUAN CHAVEZ 

Sit • Good e Sketch Address: 1822 OST • Ppor 

[g/Not paint 

Omaha Lead Site 46130 

zjy 
% 48587 

r Owner Name: JUAN CHAVEZ Omaha Lead Site 

Address: 1822 O ST Site Sketch 

Phoneutt^^pa^i^ ^ W: 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

RYASCPXA-48587 F1 3'2AB ppm D 

RYBSCPXA-48587 F2 ppm D 

RYCSCPXA-48587 B1 ppm B^ D 

RYDSCPXA-48587 B2 ppm D 

RDZOCPXA'*0507 .7 & ppm D D 

ROZOCr)CA-4Q507 CZ ppm D D 

RPZOCPXA 10607 P2­ ppm D D 

Number of Samples = ^ 

Exterior Paint North Arrow 

Q Good / • Ppor 

(JJ/Not paint 

Samples Collected 

Firmr: P E /^^4y^ 

Date: CfK' (3°L - O ^ 

Time: / x r f'Vi 

Samples Analyzed 

XRF Unit JOS l Book: I3 Z 

Date: _ / 0-7-OS -

Time: A m 

Staff: /-A 

Omaha Lead Site 46130 

£ y 
% 

48587 

r Owner Name; JUAN CHAVEZ 

Address; 1822 OST 

Phone; H^^Z-ZViS" 

Sample Numtier 

RYASCPXA-48587 Fl 

RYBSCPXA^8587 F2 

RYCSCPXA-48587 Bl 

RYDSCPXA-48587 B2 

RDZOOPXAi40S07 BZ 

rtOZOOPXA-tOSOT 6E 

RPZOCPXA 10007 PZ -

Omaha Lead Site 

Site Sketch 

W: 

Lead Sample LAB Concentration Collected 

32^3 ppm D 

^ 0 3 ppm D 

g 6 S ppm B^ n 

2 . 3 7 ppm B ^ D 

Pt)m D n 

ppm D D •" ppm D D 

Number of Samples = ^ 

6\ 

S^ fV.l&M'..l6> ^ ' ^ - - • ­

1^. 663 

(±D 

WA.1K> 

\ G sT 

Exterior Paint North Arrow 

• Good 

• Ppor < 

O^/Not paint 

Samples Collected 

Firm: P E T>cr^UL 

Date: 

Time: /•x r fTXL 

Samples Analyzed 

XRF Unit /0Z 7 Book: 13Z 

Date: _ /0-7-OS- ' 

Time: Am. Staff: AA. 

ENTERED 

iSEP 1:3 2005 

Omaha Lead Site 46130 
>* — ** 

COASTA l 

iNVmONHfHItl 

c It 0 u r I *t c 

Consent for Access To Property 

RIGHT OF ENTRY TO PREMISES 

Grantor (the property owner) consents to and authorizes the United States 

Environmental Protection Agency (EPA) or its authorized representatives, collectively 

the Grantee, to enter and perform certain environmental response aotiyitie.s jjpQn the 

following described premises: 

Owner's Name: Daytime Phone 7. y> So^ I {A ^c^Oh (K.VQ- /y r^[ f 

Address of Property 

covered by this j/-^ ^ o y Agreement: 

PURPOSE OF RESPONSE ACTIVITIES 

The EPA is requesting access to collect soil samples and remove soil that contains 

elevated concentrations of lead and may pose a health hazard. The area(s) will be 

excavated to remove contaminated soil. The removed contaminated soil will be 

replaced with clean materials and the area will be restored to its original condition. This 

work is being performed under the Omaha Lead Superfund Site remediation program. 

A representative of Coastal Environmental Group, contracted by USEPA, will contact 

the Grantor in-person to discuss the work to be perfomned, the Grantor will have an 

opportunity to review and approve the planned soil removal, and restoration work 

before it begins. Onc:e the work is finished, the Grantor will be asked to review the work 

and confirm that it is complete and meets with the Grantor's approval. Upon 

completion, the Grantor will receive written documentation from EPA that the property 

has been remediated. 

ENVIRONMENTAL RESPONSE ACTIONS 

By signing this Access Agreement, the Grantor is granting the EPA, its employees, 

contractors and subcontractors the right to enter the property, at all reasonable times 

and with prior notice, for the sole purpose of performing the work. This access shall 

remain in effect until the work has been satisfactorily completed. The Grantor also 

agrees to: 

Page 1 of 2 
> 

»'<v. 

COASTA L \ IftVIHOHHEKTAl 

'^ l PROt*^ C H O U P t K C 

( Remove obstructions including boats, trailers, vehicles, playscape items, wood 

piles, dog houses, etc; 

c Remove flower bulbs or plants that the Grantor or the Grantor's tenant may wish 

to save; 

c Water and maintain replacement vegetation, including fertilizer application, as 

necessary subsequent to an initial watering period by EPA; 

f Abide by health and safety guidance provided by EPA; 

• If the property is rented, assist EPA in obtaining tenant approval for access to 

the property to perform the work. 

c Allow videotaping and/or photographing of the property. 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tamper with any of the work activities, or with any 

of the work done, or with the equipment used on his property, or to undertake any 

actions regarding the use of said property which would tend to endanger the health or 

welfare of the Grantees or the environment, or to allow others to use the property in 

such a manner. 

Should you have any questions about this program, please contact Coastal 

Environmental Group, at (402) 991-1199 

dlgra 

D I do not grant access to my properties I grant access to my properties 

/(P'^l^/O 

Signature 

Date 

D I would like to be present during any sampling that is required. 

Page 2 of 2 
COA S T A L • HVinOMMIMTA L a • O U P . IMC . 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions of the property prior to 

remediation activities. This will also serve as documentation for the purpose of assuring that restoration 

activities are completed to the satisfaction of the property owner and the United States Enviromnental 

Protection Agency (EPA). 

Property ID: ^ / ^f ^ 

Property Address O ST 

Owner: ^ UCK^ 

Phone: r/y ry/jT 

On the attached diagram(s) indicate area(s) to excavate, surface structures and landscaping features and 

access location(s) to be used by the contractors. Indicate distances, depths, material types, etc. 

Photographically and Videographically dociunent the existing conditions ofthe property and the basement if 

necessary. 

Items to be Removed by the Owner before Start of Remediation: 

The removal, storage, disposal, and/or retum of these items is the Owner's responsibiiity. 

Kem: 

A y Z7 -770. 

Item: 

Kem: 

Kem: 

Items to be Removed by the Contractor During Remediation and Not Replaced 

Kem: 

y i y z> /y(^— 

Kem: 

Kem: 

Kem: 

Page 1 of. 7
COA S T A L • NViaONMSHTAL O M O U P . INC . 

Items to Be Removed By Contractor During Remediation and Replaced 

Kem: 

r^ A 

Hem: 

so i 

Kem: 

Kem: 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketch of the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed 

area. 

Attach a sketch of relative 

sizes and locations. 

Agreed upon value of plant 

materials not to be 

replaced by conttactor. 

Note this value will be 

used to issue a plant 

voucher to the property 

owner. 

Landscape Inventory 

Quantity 

y ­

/ 

ro 

.^0^ 

y 

y 

y 

' 

Unit Condition/Type/Species 

Quadrants 

Each 

Each 

Each 

F.ach 

Square Feet 

$ 

Easement Area, to be Each excavated f^fl^'^g ^^so y

2 

Page 2 of. 
COA S T A I. • MVmOMMaNTAL O B O U r . INC . 

AddKional Comments / Instructions: 

The city of Omaha ordinances may prohibK you from using dirt or gravel areas on your property 

as driveways or vehicle parking areas. The Environmental Protection Agency (EPA) may be 

removing and replacing soil underiying a gravel or dirt area on your property that you may be 

using as a driveway or vehicle parking area. If this is the case, you should understand that this 

removing and replacing of soil does not mean that any illegal driveway or parking area on your 

property is made legal. To the contrary, you may be cKed by the cKy if you use a gravel or dirt area 

s» a driveway or parking area, not wKhstanding any removal or replacement of soil by the EPA. 

If you have any question about legalKy of a certain driveway or parking area, you may contact 

the cKy of Omaha's Planning Department at (402) 444-5150. 

n Please check this box if you understand the information outlined above. 

' C/^ . ' 7^(^ ^ ^V A)^ ^^ '

D Check the box if Owner does not want CEG to document interior foundation walls and possible 

pre-existing damage. By checking this box CEG is not responsible for any damage done to the 

interior of house, including foundation cracks or fissures. 

n I do not agree 

i ^ pTiSu.^^^ fOl^h/( 

Date Contractor's Signature Date 

Pages .'} 
1

BVID# 48^-^1 

XRF PROPERTY SAMPLE SHEET 


Date 

Project 

XRF ID# 

 shot# 

X^o 

Vd\ 

'^'fflA 

Average

Shot # 

2^H 

T.eS' 

^"d ^ 

Average 

Shot# 

Average 

Shot# 

Average

Signature 

Print 

0'i^\liy i -LXiK. I Address 

Omaha Lead ARRA Sample time 

sample length ^^0^- ^ 

Reading Sample area Shot# 

1^2.^2.-2. F-Z 

\X^ ^ M Depth 

i^M t- t l M^' 

 \<^ 3 t X \ ^ Average 

Reading Sample area Shot# 

S-\ t^\3 ezx 

S3 ^ \3 Depth 

H:^ ^V3 \ " 

?o ^ \3 / Average 

Reading Sample area Shot# 

Depth 

Average 

RETEST AREAS 

Reading Sample area Shot# 

• ) 

/ ^ / Depth 

/ / 

/ Average 

( •yy^-- Wlftf^ yym^"^ 

i(?nrL 0 Sr­ am/pm 

30 sec 

Reading Sample area 

Depth 

Reading. Sample area 

Depth 

Reading Sample area 

Depth 

Reading Sample area 

Depth 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By 

Certificate of Verification 

283 

SOIL 

2011-02-22 19:54 

90.76 

Final 

Avg of 280-2821 

1822 O St^ 

F2 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 192.733 

Supervised By: 

Certificate of Verification 

280 

SOIL 

2011-02-22 19:53 

30.28 

Final 

48587 

1822 O ST 

F2 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 22.107 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 193.282 

Supervised By: 

Certificate of Verification 

281 

SOIL 

2011-02-22 19:54 

30.24 

Final 

48587 

1822 O ST 

F2 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

Error 

± 21.894 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 194.114 

Supervised By: 

Certificate of Verification 

282 

SOIL 

2011-02-22 19:54 

30.24 

Final 

48587 

1822 O ST 

F2 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 21.599 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By 

Certificate of Verification 

287 

SOIL 

2011-02-22 19:57 

90.11 

Final 

Avg of 284-286 

1822 O ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm

Pb 51.707

Supervised By: 

Certificate of Verification 

284 

SOIL 

2011-02-22 19:56 

30.02 

Final 

48587 

1822 O ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 13.595 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 53.293 

Supervised By: 

Certificate of Verification 

285 

SOIL 

2011-02-22 19:57 

30.05 

Final 

48587 

1822 O ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 13.755 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm

Pb 45.412

Supervised By: 

Certificate of Verification 

286 

SOIL 

2011-02-22 19:57 

30.04 

Final 

48587 

1822 O ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 13.373 
Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmentai Group Inc. 

www.coastalhazmat.com 

COASTA L IN«l>ONMiNTAl 

G > 0 U P, IN C 

EXECUTIVE SUMMARY: 

BVID #48587-(1822 O ST) 

No Issues or Concerns I I Issues/Concerns 

Detail Explanation 
Sti!^ 

EPA Property Close Out Form 

^IZ O'TTT 

Property #: . t Property Address: 

Date/Time: 12 m Owner's Name:. /,73^ ^ 

L 

Quads Excavaled: PE Contractor Group (^'ft*^ ^ & 

Excavation General Yes No 

1. ir necessaiy, were the conrect quadrant(s) excavated and restored? y 

2. If necessaiy, were the correct areas of drip zone excavated and restored? y 

Gradloe Sod and Vcuctalioa Yes No 

1. Does the gnding around the perimeter ofthe house in excavated areas generBlly slope away / from tbe house? 

2. Has sod been laid m all areas that were excavated? y 

3. Does die sod appear to be generally healthy and growing? (Only evaluate if inspected at a 30 y day time period) 

4. Are sodded areas generally firm and evenly graded? y 

5. Are die joints betweett the sod strips generally tight? (Only evaluate if inspected at a 30 day 

time period) y

6. Was the property graded such that water will not pool on the property? / 

7. Was damage lo landscaping or plant materials avoided? 7 

Gates. Fences antl Retafailng Walb Vts .No 

I 1. Do gates open and close freely? (If applicable) y 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicable) 7 

3. Was damage to gates or fences avoided? (tf applicable) 7 

4. Was damage to retaining walls avoided? (Ifapplicable) 7 

Foundation, SidiBR and Gulttrs Yes .No 

I. Was damage to the siding or trim avoided? / 

2. Was damage to the foundation avoided? y 

Was damage to windows avoided? / 

A Was dainage to windows or door screens avoided? / 

S. Was damage io downspouts or downspout extensions avoided? / 

Sidewalks and Driveways (Concrete) Yes No 

I. Was damage to driveway surfaces avoided? / 

2, Wai damage to walkway surfaces avoided? T 
Ort'oers comnieiits: 

I 

pjinspection notes: 

Removal and restoration aclivales coinpiele including the 30-day sod warranty: 

EPA Representative fto^ A^'y Date: »*M'£_ 
I

Property Completion Agreement 

This agreement documenli lhe completion ol remedial activities perlbimed on my pioperly My signature 

will designate thai I am satisfied with (he restoralion of my properly, and thai no items are in queslions. 

now. or al any lime in the future, excepl those items listed below, ifany 

Property ID: ^/5^^ 

PropertyAddress: \^l^Z^{ ) %f " 

Owner: -g^jQU ^ 

Phone: 7/^- S^7. U/<y^ - 0

Restoration Items in Question: 

Item: 

Item: 

item; 

Item: 

Item: 

Item: 

 I I agree rKtoralion is completed, rxccpt as noleri 

I do nol ii|>rtc restoratinn i i completed 

Contiactor's Signalure